Provider Demographics
NPI:1023206265
Name:PROGRESSIVE CHIROPRACTIC WELLNESS & REHAB CENTRE, P.C.
Entity Type:Organization
Organization Name:PROGRESSIVE CHIROPRACTIC WELLNESS & REHAB CENTRE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-636-2225
Mailing Address - Street 1:6270 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6270 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4418
Practice Address - Country:US
Practice Address - Phone:815-636-2225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009877305S00000X
IL038009629305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU94676Medicare UPIN
IL205345Medicare PIN
ILU94675Medicare UPIN